key: cord-0059041-15pk32xc authors: Franco, Diana title: COVID-19 as Post-Migration Stress: Exploring the Impact of a Pandemic on Latinx Transgender Individuals in Immigration Detention date: 2020-09-29 journal: Shared Trauma, Shared Resilience During a Pandemic DOI: 10.1007/978-3-030-61442-3_32 sha: 60dd6384d010bbb0e0c542bb7a84a99484fb7847 doc_id: 59041 cord_uid: 15pk32xc Transgender asylum-seeking individuals are often exposed to traumatic events in their country of origin, during the migratory journey, and post-migration. As a host country, the United States disproportionately targets Latinx migrants through persecutory anti-immigration, nativist laws, and xenophobia. Many Latinx transgender individuals with precarious immigration statuses must await decisions about their cases in immigration detention centers. Detention centers have been criticized for a host of health and physical safety threats, such as sexual assault by guards and other detainees, physical violence, and negligence resulting in death. Coronavirus (COVID-19) has had a substantial impact on the lives of Latinx transgender migrants in detention by amplifying pre-existing stressors. Among these challenges is the limited access to mental health care and psychological evaluations needed to treat and determine histories of trauma, depression, and acute stress in credible fear asylum cases. The resilience framework will be used to address shared trauma between Latinx transgender migrants in detention and clinicians in coping with COVID-19-related barriers to therapeutic services. linked to an exacerbation in pre-existing trauma symptoms in transgender individuals (Castro 2020; Evans 2020; Human Rights First n.d.) . Latinx transgender migrants need access to mental health treatment and other necessary health services, especially amid the current COVID-19 pandemic. COVID-19 has had a substantial impact on the lives of Latinx transgender individuals in detention by exacerbating these pre-existing stressors. According to the World Health Organization (WHO) (2020), COVID-19 is an infectious, respiratory disease, now considered a pandemic affecting many countries in the world. Because of its high contagion factor, COVID-19 poses barriers in accessing mental health care to treat and assess histories of trauma, depression, and acute stress in credible fear asylum cases. In my role as a volunteer clinician, I conduct psychological evaluations in Spanish for Latinx transgender individuals in detention. As a result of COVID-19, this author and other clinicians have not been able to conduct psychological evaluations or have been limited to conducting these through a remote, virtual platform. This chapter will focus on the unique needs of Latinx transgender individuals in detention and the challenges in service delivery imposed by COVID-19 restrictions. This pandemic barrier to mental health creates a multilevel problem in conducting psychological evaluations and delays and obstructs positive outcomes in pending asylum cases, which creates an indeterminate state in assessing credible fear and establishing a timely mental health diagnosis. Lack of access to mental health also places transgender individuals in detention at risk of worsened psychiatric symptoms, including suicide (Reisner et al. 2016) . This may also result in feelings of disempowerment and helplessness in the clinician. The resilience framework will be used to address shared trauma between Latinx transgender individuals in detention and clinicians in coping with COVID-19related barriers to therapeutic services. Individuals forced to flee from their countries of origin are exposed to traumatic events throughout the three phases of migration: pre-migration, in-journey, and post-migration (Franco 2018) . LGBTQIA+-identified migrants, specifically transgender migrants, are among the most vulnerable in the world (US Department of State n.d.). Latinx transgender migrants arrive to the United States with complex trauma histories, including significant symptoms of depression, anxiety, and posttraumatic stress disorder (Keller et al. 2003) . Transgender individuals worldwide are displaced from their countries of origin due to persecutory laws based on their gender identity and expression. In keeping with this notion, Latinx transgender individuals around the globe face discrimination in obtaining employment, attending school, and engaging in day-to-day activities and, in many cases, are threatened by death and live in constant fear for their lives (Moloney 2019) . The journey to the United States, which seems a promising choice is, in reality, fraught with danger and threats. Throughout this perilous journey, human smugglers and gangs force Latinx transgender women into human trafficking, and they are often sexually abused and raped (Del Real 2018) . Once in the United States, Latinx transgender migrants are subjected to persecution based on gender identity, race, and immigration status (Klein 2020) . If apprehended by Immigration and Customs Enforcement (ICE) or US Customs and Border Protection (CBP), Latinx transgender individuals are placed in immigration detention centers. Therefore, Keller and Wagner (2020) suggest that "for such traumatized individuals, immigration detention can cause severe psychological distress, including depression and post-traumatic stress disorder" (p. e245). COVID-19 increases fear in transgender detainees, therefore functioning as a post-migration stressor that compounds pre-existing complex trauma. Hazardous conditions at immigration detention centers also pose threats to the psychological safety of these individuals. Klein (2020) suggests that COVID-19 disproportionately affects the mental health of LGBTQIA+-identified individuals because some members of this group may be at risk for substance use, depression, and other psychological sequelae (p. 240). Additionally, individuals with intersecting identities such as being a migrant and a sexual and gender minority, or "undocuqueer," may experience increased social marginalization during a pandemic (Klein 2020, p. 241) . Social distancing may worsen symptoms of depression in non-detained LGBTQIA+identified individuals (Klein 2020) ; therefore, migrants in detention may experience similar mental health outcomes. Similarly, Keller and Wagner (2020) suggest that "continued imprisonment during this pandemic could result in even more severe harm to the mental health of immigrant detainees" (p. e245). Immigration detention centers have long been criticized for exposing detainees to a host of psychological and physical health hazards, including inhumane treatment, overcrowded conditions, inadequate and substandard medical care, and poor hygiene (Fitzsimons 2020; Montoya Galvez 2020; Vinson 2020). COVID-19 has exacerbated these pre-existing health conditions, revealing human rights violations and social justice concerns (Fitzsimons 2020) . To date, there are 22,835 detainees in ICE detention, of which 13,562 have been tested for COVID-19 and 3029 have tested positive for this virus (Detained in Danger 2020). These numbers indicate that COVID-19 is spreading rapidly in immigration detention centers. Transgender migrants in detention find it challenging to protect themselves from contagion. Some of these challenges include a disregard for Centers for Disease Control and Prevention (CDC) social distancing protocols by guards, tests administered solely to symptomatic detainees, insufficient access to testing, and a lack of access to personal protective equipment (PPE) (Chang 2020; Fitzsimons 2020; Kerwin 2020; Openshaw and Travassos 2020) . To illustrate, a 20-year-old Latinx transgender woman in immigration detention stated that guards often do not wear PPE, detainees are forced to share common areas with feverish individuals, and requests to see medical staff may take up to 4 days for symptomatic detainees (Vinson 2020) . This individual reported that "being surrounded by men during the COVID-19 pandemic has been worse than the violence she fled in Mexico" and indicated feeling depressed and anxious (Vinson 2020, pp. 33-34) . Another Latinx transgender woman in detention reported feeling scared, vulnerable, and unprotected from COVID-19 (Fitzsimons, 2020) . These physical and psychological safety concerns, aggravated by COVID-19, function as post-migration stressors and trauma triggers in Latinx transgender individuals in detention. Delays and denial of physical and psychological services serve to increase and compound fear in detainees, affirm their invisibility in society, and augment trauma symptoms. COVID-19 restrictions have forced clinicians to shift to virtual platforms, phone calls, or suspend in-person psychological evaluations altogether. As stated previously in this chapter, the psychological evaluation is an essential component in asylum cases. The psychological evaluation is a mechanism that allows for the provision of diagnostic information that may support the applicant's claims, determine credibility, elicit trauma narratives, and provide additional services to applicants who have been victims of torture (McKenzie et al. 2018; Meffert et al. 2010) . Mental health professionals are essential in cases where torture has been alleged, since torture does not always leave physical scars but can manifest as posttraumatic stress, depression, anxiety, and other psychological sequelae (McKenzie et al. 2018) . The evaluation consists of documenting forensic evidence in the form of a medicolegal affidavit, addressing a range of inflicted harms such as torture, rape, persecution, and other abuses -a process that can take anywhere from 3 to 6 h per case (McKenzie et al. 2018; Mishori et al. 2016 ). This evaluation process, while rewarding for the clinician, can also be concurrently physically and emotionally taxing. Many clinicians who conduct asylum psychological evaluations do so as volunteer evaluators. Clinicians working with asylum cases report feeling motivated by "humanistic and moral values, noted personal and family experiences, having skills, expertise, and career interests as drivers" (Mishori et al. 2016, p. 210) . However, while most clinicians have reported feeling positive about conducting these evaluations and find it personally and professionally rewarding (McKenzie et al. 2018, p. 137) , some reported mixed feelings described as the "most horrible and most gratifying experience" and "harrowing, but rewarding" (Mishori et al. 2016, p. 214) . The content that emerges during asylum psychological evaluations -often intense trauma narratives -can be overwhelming for the clinician (Meffert et al. 2010 ). This may result in the clinician and the detainee experiencing "shared trauma," a term offered by Dr. Carol Tosone to explain when the therapist and the service user share collective trauma (Tosone 2020) . As a result, the clinician may experience a countertransferential need to advocate for the detainee or bias the content of the evaluation (Meffert et al. 2010) . "Countertransference" is used to describe the unconscious or conscious emotional or behavioral reactions of the clinician to the service user and is a process that may emerge in the therapeutic setting (Tosone et al. 2012, p. 232) . Clinicians with similar backgrounds or trauma histories to the detainees may experience similar feelings. This author is a Latinx first-generation migrant who grew up in a family with mixed migration statuses: lawful permanent residents, US citizens, and undocumented individuals who began their journey in South America and arrived in the United States via the US-Mexico border. The author and her family have experienced oppression, racism, and discrimination based on their ethnicity and immigration histories. Therefore, conducting evaluations with this vulnerable population has triggered her own grief, anger, powerlessness, and the shared trauma of oppression and racism, unbeknownst to the interviewee. For clinicians motivated by altruistic and humanistic values, barriers posed by COVID-19 restrictions in conducting asylum evaluations may trigger feelings of hopelessness and immobilization as they are forced to socially isolate. Similarly, Latinx transgender individuals in detention also feel helpless, vulnerable, and powerless as their cases remain in legal limbo. Literature (Tosone 2020; Brooks et al. 2015) suggests that shared trauma in crises and disasters can be understood through the resilience framework. Resilience has been linked to lower levels of stress and improved interpretation of the situation and response. Resilience, often defined in various ways within the literature, has been commonly defined as the ability to recover and bounce back from difficult events and then to integrate the disruptions and accommodate (Brooks et al. 2015; Pfefferbaum et al. 2017 ). Specifically, psychological resilience "relates to the adaptation of individuals after trauma, and that certain 'protective' factors may influence the extent to which individuals adapt" (Brooks et al. 2015, 386) . However, some literature suggests that the resilience framework has shifted its focus from the experience of trauma to its role and application in managing difficult situations through emotion regulation and problem-solving (Bostelman 2020) . For example, many clinicians have observed high levels of hope, courage, and resilience in asylees and in transgender women of color (Mishori et al. 2016; Ruff et al. 2019) . Sexual-and gender-displaced minorities, such as Latinx transgender individuals in detention, promote resilience in their lives by staying hopeful and positive and relying on the legal services available to them (Alessi 2016) . In this author's experience, many detainees develop supportive bonds with one another from where they draw hope and meaning in their lives. Nuttman-Shwartz (2014) refers to "shared resilience in a traumatic reality" as a way in which clients and clinicians can experience resilience as a result of exposure to the same communal disaster (p. 1). To process shared trauma in a pandemic, clinicians may foster resilience in their lives by joining peer support groups, attending supervision sessions, and limiting media exposure (Meffert et al. 2010; Spiegel 2020; Tosone et al. 2012) . Reaching out through virtual platforms to connect with other volunteer clinicians in asylum cases has been a source of support for the author, and communicating with immigration attorneys on upcoming plans to bridge gaps in services to Latinx transgender migrants in detention has reversed feelings of powerlessness and hopelessness. Self-care is also an essential component to fostering resilience in a pandemic (Spiegel 2020). The author has found it beneficial to engage in more outdoor activities such as running and hiking, while adhering to social distancing protocols. COVID-19 affects us all, albeit in different ways. Being intentional in maintaining social support and personal self-care can be essential in developing resilience during such uncertain times. Resilience in sexual and gender minority forced migrants: A qualitative exploration Cultivating resilience in correction systems Risk and resilience factors affecting the psychological wellbeing of individuals deployed in humanitarian relief roles after a disaster TLC, Ballard Spahr, & Rapid defense network announce class action lawsuit to free all transgender people in ICE custody Detained in danger: Database raises troubling questions about COVID-19 in ICE detention centers They were abusing us the whole way': A tough path for gay and trans migrants. The New York Times ICE detaining transgender individuals despite widespread calls for their release Class action suit aims to free all transgender ICE detainees Trauma without borders: The necessity for school-based interventions in treating unaccompanied refugee minors Immigration detention: We press the U.S. government to end harmful immigration detention centers COVID-19 and immigration detention in the USA: Time to act. The Lancet Mental health of detained asylum-seekers Immigration detention and COVID-19: How the US detention system became a vector for the spread of the pandemic. Center for Migration Studies Rethinking COVID-19 vulnerability: A call for LGBT+ im/migrant health equity in the United States during and after a pandemic Asylum seekers in a time of record forced global displacement: The role of physicians The role of mental health professionals in political asylum processing Their stories have changed my life": Clinicians' reflections on their experience with and their motivation to conduct asylum evaluations LGBT+ murders at 'alarming' levels in Latin America -Study ICE resists calls to release immigrants as desperation mounts over coronavirus Shared resilience in a traumatic reality: A new concept for trauma workers exposed personally and professionally to collective disaster COVID-19 outbreaks in U. S. immigrant detention centers: The urgent need to adopt CDC guidelines for prevention and evaluation. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America, ciaa692 A conceptual framework to enhance community resilience using social capital Global health burden and needs of transgender populations: A review Hope, courage, and resilience in the lives of transgender women of color Shared trauma during a pandemic Shared trauma: When the professional is personal At-risk populations: Bureau of populations, refugees, and migration Transgender woman endures transphobic abuse in immigration prison during pandemic. Southern Poverty Law Center Q & A on coronaviruses (COVID-19). World Health Organization